The Impact of Lean Management on Primary Care Efficiency, Affordability, and the Patient Experience

 描述(由申请人提供)：尽管美国拥有世界上最高的医疗支出水平，但在包括提供的医疗服务效率和质量在内的关键领域排名最后。医学研究所估计，由于护理服务设计和治疗模式中的系统性缺陷，每年浪费7650亿美元，并敦促迅速学习系统以提高绩效。然而，在降低成本或提高效率方面取得成功，绝不能以牺牲向患者提供的护理质量为代价。“精益”管理是一种以行业为基础的干预措施，在最大限度地提高效率、最大限度地降低成本以及提高交付给消费者的产品和服务的质量方面取得了成功。精益正在迅速成为公共和私人医疗系统中用于提高短期效率和质量的领先方法之一，同时作为长期系统转型的基础。尽管在卫生保健中越来越多地采用精益，但很少有关于其影响的严谨研究，特别是将精益作为 全系统改进成本和质量措施。本研究的目的是探讨精益管理对几个重要结果的影响。具体地说，目标1将确定精益流程改进对技术效率的影响，以相对于所提供的服务的投入(例如，用品、医生和非医生的时间和人员配备)来衡量。目标2将探讨精益对卫生系统可负担性的影响，如每个患者群体和每个急慢性护理阶段(背痛、支气管炎、糖尿病、高血压)的资源使用情况，同时监测临床质量的趋势。最后，目标3将评估影响 通过检查患者报告的满意度、访问权限(例如，办公室访问、提供者对患者消息的响应时间)的变化， 和病人流量(例如，在等候/检查室花费的时间)。这些指标将在46个初级保健部门进行检查，这些部门分布在近20个地理位置各异的大型医疗保健提供系统中，为四个县的近100万名患者提供服务。由于精益是以系统分阶段的方式实施的--首先是在一个试点诊所，然后是三个“测试”诊所，然后是交错实施开始时间的13个剩余诊所--这个已经完成的自然实验提供了一个独特的机会，可以利用现实世界的操作活动进行严格的科学研究。分段回归的准阶梯楔形设计将应用于组织指标和医生/患者时间数据，并使用我们带有时间戳的EHR系统以新颖的方式进行记录和分析。这项拟议研究的结果将大大增加对医疗保健中精益的了解，并可能在精益作为一种工具越来越受欢迎的情况下，使科学、实践和政策社区受益 提高美国医疗保健的价值。

 DESCRIPTION (provided by applicant): Despite having the highest levels of healthcare spending in the world, the U.S. ranks last in key areas including the efficiency and quality of care delivered. The Institute of Medicine estimates that $765 billion dollars are wasted every year due to systemic flaws in care delivery designs and treatment patterns, and urges rapid system learning to improve performance. Success in reducing cost or increasing efficiency, however, must not be achieved at the expense of the quality of care delivered to patients. "Lean" management is an industry- based intervention that has been successful in maximizing efficiencies, minimizing costs, and improving the quality of products and services delivered to consumers. Lean is rapidly becoming one of the leading methods used in both public and private healthcare systems to improve short-term efficiency and quality, while serving as a foundation for longer-term system transformation. Despite the increasing adoption of Lean in health care, there are few rigorous studies of its impacts, and particularly of Lean as a basis for system-wide improvement in cost and quality measures. The goal of this study is to explore the impacts of Lean management on several important outcomes. Specifically, Aim 1 will determine the impact of Lean process improvements on technical efficiency, as measured by inputs (e.g., supplies, physician and non-physician time and staffing) relative to services provided. Aim 2 will explore Lean implications for health system affordability, as indicated by resource use per patient population, and per acute and chronic episode of care (back pain, bronchitis, diabetes, hypertension), while monitoring trends in clinical quality. Finally, Aim 3 will evaluate the impact of Lean redesigns on patient experiences with care delivery by examining changes in patient-reported satisfaction, access (e.g., to office visits, provider response time to patient messages), and patient flow (e.g., time spent in waiting/exam room). These metrics will be examined in 46 primary care departments across nearly 20 geographically distinct clinic locations of a large, healthcare delivery system serving nearly one million patients across four counties. As Lean was implemented in a systematically staged manner-first in one pilot clinic, then three "beta" clinics, followed by thirteen remaining clinics with staggered implementation start times-this already completed natural experiment allows a unique opportunity to leverage real-world, operational activities for rigorous, scientific study. A quasi-stepped wedge design with segmented regression will be applied to organizational metrics and physician/patient time data as documented and analyzed in novel ways using our time-stamped EHR system. Findings from this proposed study would add substantially to knowledge about Lean in health care, and may benefit scientific, practicing, and policy communities as Lean grows in popularity as a vehicle for improving value in U.S. health care.